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Leaving for Boston

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In a few days, our specialists will attend the international annual SOSORT conference, which will be held in Boston, USA, from May 1 to 4 (please visit the website to register for the event or to learn more about it).  

ISICO will present a remarkable number of eight abstracts during the conference, two of which are Personal and Clinical Determinants of Brace-Wearing Time in Adolescents with Idiopathic Scoliosis and Influence of Specific Interventions on Bracing Compliance in Adolescents with Idiopathic Scoliosis — A Systematic Review of Papers Including Sensors’ Monitoring.

Both abstracts focus attention on the treatment of idiopathic scoliosis with braces, the factors that determine patient compliance, and its objective measurement. Bracing is, in fact, an effective treatment for medium-degree curves, and thermal sensors help monitor patients’ adherence (compliance), a critical issue in bracing treatment.  

Influence of Specific Interventions on Bracing Compliance in Adolescents with Idiopathic Scoliosis—A Systematic Review of Papers Including Sensors’ Monitoring underlines that high adherence to brace prescription is fundamental to gaining the maximum benefit from adolescent idiopathic scoliosis (AIS) treatment approach. Having an objective measure of compliance provided by the sensors allows the clinician to make informed decisions and prescribe therapy in a personalized and sustainable manner, balancing therapeutic efficacy with the patient’s daily needs and difficulties, but the use of wearable sensors is poorly investigated.

“Wearable sensors are available that objectively monitor the brace-wearing time, but their use, combined with other interventions, is poorly investigated.- explains prof. Stefano Negrini, ISICO Scientific Director and one of the authors of the research – We conducted a systematic review of the literature published (466 articles and included examples articles) to summarize the real compliance with bracing reported by studies using sensors; to find out the real brace wearing rate through objective electronic monitoring; to verify if interventions made to increase adherence to bracing can be effective according to the published literature”. 

The research Personal and Clinical Determinants of Brace-Wearing Time in Adolescents with Idiopathic Scoliosis‘ performed a cross-sectional study of 514 adolescent patients consecutively recruited in the last three years at a tertiary referral institute and treated with braces for one year.

“Some studies investigated adherence determinants but rarely through sensors or in highly adherent cohorts – tells Dr. Giulia Fregna, one of the authors of the research  – We aimed to verify the influence of personal and clinical variables routinely registered by physicians on adherence to brace treatment in a large cohort of consecutive AIS patients from a highly adherent cohort. We have identified gender, age (considered alongside bone age), and the “bracing hours prescription” as critical determinants of adherence behaviour. These findings underscore the importance of tailoring interventions to address the specific needs of different patient populations”.

Dr. Sabrina Donzelli, the next president, tells us about the SOSORT conference

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Once again, the international SOSORT conference was one of the most important appointments for our institute (eight abstracts were presented), and with a cherry on top, the fifth SOSORT Award was won!
We asked Dr Sabrina Donzelli, physiatrist and president of SOSORT in 2024, the first woman to hold this position, to tell us something more about the event, given that she was one of the three Isico specialists present in Melbourne (the others were Dr Fabio Zaina and our director of physiotherapy, Michele Romano).

1) What did participating in this event mean to you?
For the first time, SOSORT participated in Spineweek. Spineweek is an event that occurs every four years and brings together many societies dedicated to various aspects of the spine. This event allows participants to follow different companies by participating in a single event. It provides the other companies involved greater visibility or the possibility of being known and attracting new members.
The event was a success for SOSORT thanks to the number of participants and presentations. SOSORT is growing, and this experience was another opportunity for growth for the company, which is preparing to organize its first annual congress with total autonomy.

2) What were the major scientific innovations?
Dr Angelo Aulisa presented a remarkable study on the efficacy of braces in patients with Scheuermann with a 10-year follow-up. It is the first study to explore this area with such an extended follow-up.
Comparison studies are starting to emerge, for example, between braces at different dosages or nighttime bracing compared with exercises only; unfortunately, the quality of these studies is limited, and the results still need to be evaluated with caution.
We are also witnessing an increasing collaboration between surgery and rehabilitation treatment in a great communication effort to learn how to manage better patients who have surgical indications and those who would like a surgical approach but could benefit from conservative treatment. The president of the SRS (Scoliosis Research Society), Dr Serena Hu, showed the innovations in the surgical field; indeed, there are still many challenges to reducing invasiveness with the same effectiveness.

3) The SRS also has a female president for the first time, and your successor in the SOSORT presidency is the Croatian doctor Suncica Bulat Wuerching. There are more and more women, so how are you experiencing this moment of transition to your presidency?
We women play a fundamental role in the scientific world, like our colleagues, and this can only fill me with satisfaction for the work we carry out with great determination and professionalism. In terms of my position, it will be a great responsibility to lead the company through this transition. Still, I am delighted to work with a fantastic team of professionals, starting with the current president, James Wynne.

Adherence to treatment: the abstract for Sosort Conference

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“Adherence to Physiotherapeutic Scoliosis-Specific Exercises during adolescence: voices of patients and their families. A qualitative content analysis” is one of the 8 studies being presented by ISICO during the forthcoming SOSORT international conference in Melbourne, Australia.
Its purpose was to explore the experience with PSSE of adolescents with spinal deformities and their parents, and their insights on how to assess the quality and frequency of PSSE performed at home.
The study is the exploratory phase of the development of a new Rasch-consistent questionnaire to assess adherence to PSSE in adolescents with spinal deformities. 

“The efficacy of specific exercises for scoliosis is closely linked to patient adherence to the treatment programme,” says Dr Irene Ferrario, ISICO psychologist and author of the study. “Treatment adherence is a complex concept, as it is the result of the interaction of various factors associated with patients, families, therapists and the treatment itself. Managing to identify the factors that promote or prevent treatment adherence is crucial in order to help youngsters get the best possible result. In this study, we set out to look at how our patients and their parents get on with scoliosis exercises, and examine their ideas on how the quality and the quantity of exercises done at home might be assessed”.

How did we collect the data? The researchers sent 2699 patients a questionnaire made up of open questions designed to collect thoughts and experiences with respect to adherence to a home exercise programme; 110 adolescents and 93 parents filled in the questionnaire anonymously. On the basis of what they wrote, we identified the five main categories of factors that can facilitate or hinder treatment adherence: “Organisation of time and space”, “Help tools”, “Understanding the therapeutic goals”, “Loneliness”, and “Nature of the exercises”.  

The most commonly reported facilitating factors were: using an app specially developed by ISICO, being able to listen to your favourite music while doing the exercises, being able to decide when to schedule the home sessions, and certain characteristics of the exercises (e.g., easy, fun, not requiring specific instruments). The factors most commonly deemed to hinder treatment adherence were lack of time, lack of motivation, lack of feedback from the physiotherapist, and type of exercises (i.e., boring ones).

“Patients and their families know what can help or interfere with their adherence to a home exercise programme for scoliosis” Dr Ferrario concludes. “Listening to what they have to say about the various factors that can hinder or facilitate them in this regard can help physiotherapists to develop exercise programmes tailored to patients’ specific needs and offer solutions and strategies to overcome common problems, thereby helping youngsters to more easily achieve the goals of the treatment.”

SOSORT 2022: the AWARD winners and a fourth ISICO President

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This year’s SOSORT meeting, held in San Sebastian, Spain in the wake of two editions forced online by the pandemic, was a double success for ISICO, which had two studies shortlisted for the SOSORT Award.
One of them, Prediction of Future Curve Angle using Prior Visit Information in Previously Untreated Idiopathic Scoliosis: Natural History in Patients under 26 Years Old with Prior Radiograph, conducted in collaboration with the University of Alberta in Canada, came first, making this the fourth consecutive year that ISICO has taken home the prestigious award. But this was not the only high point. Our Dr Sabrina Donzelli, physiatrist, was named as the next President of the International Society. This is the fourth time that ISICO has had this has honour since SOSORT was founded in 2004,  and it is the first time a woman has been appointed to the role.

“This prestigious appointment is an acknowledgement of Dr Donzelli’s scientific standing, hard work and commitment, as well as a recognition of our institute, which now provides a benchmark for clinical and research activity worldwide” remarked Prof. Stefano Negrini, Scientific Director of ISICO as well as one of the ISICO authors — the others being De Giulia Rebagliati, Dr Fabio Zaina and Dr Alberto Negrini — who collaborated with Dr Eric  Parent, first author of the study that won the SOSORT AWARD. The congress was hugely stimulating and we can’t wait for 2023 and next year’s meeting in Melbourne, Australia”.

Ready for SOSORT

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There are just a few days and the SOSORT  International Conference finally, after two years from the start of the pandemic, is back in person in San Sebastian, Spain from the 4th to the 7th of May.
It will be the usual pre-course, scheduled for May 4, to kick off the event: three of our specialists will participate in the round table, Dr Fabio Zaina, with a session on Overview of Adult Spinal Deformity classification, and how it is differing from AIS, Dr Sabrina Donzelli with  ASD prevalence and Dr Michele Romano, director of Isico Physiotherapy, with Standardized presentations describing assessment, clinical decision making process and treatment.

In the following days, Isico will be present again with three presentations: Dr Fabio Zaina will present on May 6th “Night-time bracing improves back pain in patients with painful scoliosis: six months results of a retrospective controlled study“, Dr Michele Romano on May 7th “Exercises for adolescent idiopathic scoliosis: Updated Cochrane Review”  and finally, Prof. Stefano Negrini, scientific director of Isico, will compete for the SOSORT Award with his research “Splitting Growth into 3 Phases with Cut-offs at Pubertal Spurt and Risser 3 Facilitates Prediction of Progression. A Study of Natural History of Idiopathic Scoliosis Patients from age 6 to End of Growth”.

For more info: https://sansebastian2022.sosort.org

Curves measuring less than 10 degrees: should we treat them?

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As suggested by the Scoliosis Research Society (SRS), a scoliosis diagnosis is confirmed when a patient presents a Cobb angle measuring 10° or more and axial vertebral rotation. Maximum axial rotation is measured at the apical vertebra. (1) The SRS established this threshold in 1977, replacing the previous one of 7°. Ever since, 10 ° has conventionally been accepted, worldwide, as the threshold for diagnosing scoliosis.
However, structural scoliosis, with a potential for progression, can also be observed in the presence of Cobb angles measuring less than 10°. In fact, initial wedging of the vertebral bodies and disks can sometimes be registered with curves of 4°–7°. (2)

Idiopathic scoliosis, being a developmental disorder, most commonly arises and progresses during periods of accelerated growth (growth spurts).

The first such period occurs in infancy/early childhood, generally between 6 and 24 months of age, and the second between the ages of 5 and 8 years; finally, there is the pubertal growth spurt, which generally occurs at 11–14 years of age. (1)

Although the later stages of development are obviously not risk free, after puberty the rate of growth usually slows down, reducing the risk of progression of scoliosis. 

Can the risk of scoliosis progression be predicted in the case of curves measuring less than 10°?
There is, of course, always a chance that these curves will become more pronounced as the youngster grows, even, in some cases, to the point of requiring the use of a brace. But it is also true that most of them will remain stable over time without reaching the minimum criteria for a diagnosis of scoliosis. Certain factors may possibly be associated with an increased risk of scoliosis progression: a positive family history of scoliosis, laxity of ligaments, flattening of physiological thoracic kyphosis, a greater than 10° angle of trunk rotation (ATR), and growth spurts. All these factors should be evaluated by the attending physician. 

So, should we be treating these youngsters? In short, no. First of all, it is worth remembering, that the main aim of conservative treatment of scoliosis is to improve the patient’s appearance, but curves as mild as this rarely have an aesthetic impact; at most there may be some slight asymmetry of the trunk, but nothing that can be considered to exceed physiological parameters. With very rare exceptions, the only advice necessary in these cases is to opt for clinical monitoring of the patient, which can be considered to all intents and purposes a treatment, in the sense that it allows us to overcome the critical phases of development (which also correspond to the periods of greatest risk of progression of scoliosis) and also to intervene if any progression does occur. Monitoring is the first step in an active approach to idiopathic scoliosis, and it consists of clinical evaluations performed at regular intervals, ranging from every 2-3 months to every 36-60 months depending on the single case. 

In conclusion, any active treatment in this population of patients is actually overtreatment. Even just specific exercises, whose prescription constitutes first therapeutic step after monitoring alone, would cost these youngsters in time and effort, as well as being an economic cost.

A further aspect, not to be underestimated, is the psychological impact: starting a treatment amounts to confirming that the individual has a disease that needs to be treated, and this can lead them to start thinking of themselves as “sick”.

Furthermore, even though an exercise programme is not a particularly arduous undertaking, starting a treatment when there is no real need for one could compromise the youngster’s collaboration and commitment should a treatment be needed later on. This is an important consideration, because if their scoliosis does progress as they grow, specific exercises, rather than being useful, could become crucial, in order to avoid bracing for example.  

1 – 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth

https://pubmed.ncbi.nlm.nih.gov/29435499/

2 – Radiographic Changes at the Coronal Plane in Early Scoliosis. Xiong, B., Sevastik, J. A., Hedlund, R., & Sevastik, B. (1994). Spine, 19(Supplement), 159–164. doi:10.1097/00007632-199401001-00008

https://pubmed.ncbi.nlm.nih.gov/8153824/

The experts’ brace-classification : a newly pusblished study with video-commentary

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Studies have shown that brace treatment for AIS is effective but not all braces are the same. The classification of scoliosis braces developed by SOSORT with SRS, ISPO, and POSNA and approved by ESPRM, a study just published by The European Spine Journal, aims to produce a classification of the brace types.Studies have shown that brace treatment for AIS is effective but not all braces are the same. The classification of scoliosis braces developed by SOSORT with SRS, ISPO, and POSNA and approved by ESPRM, a study just published by The European Spine Journal, aims to produce a classification of the brace types.
Four scientific societies (SOSORT, SRS, ISPO, and POSNA) invited all their members to be part of the study. Six level 1 experts developed the initial classifications. At a consensus meeting with 26 other experts and societies’ officials, thematic analysis and general discussion allowed to define the classification (minimum 80% agreement).
The classification was applied to the braces published in the literature and officially approved by the 4 scientific societies and by ESPRM.
There are substantial differences in results published in the literature: one of the factors impairing research and leading to clinical confusion in the field is the absence of a classification to understand differences and commonalities among braces.
The only existing classification is common to all other orthoses, which is to classify braces according to the anatomical joints held underneath the brace—in the spine, these are the trunk regions. Unfortunately, according to this classification, almost all braces for spinal deformities fall in the thoracolumbosacral orthosis (TLSO) category, without other differentiations included.
As a result, clinicians cannot generalize research results on one brace to another with the same biomechanical action. Even worse, we could be inaccurately generalizing data on one brace to another brace with different biomechanical actions.
In this study the experts developed a definition for each item and were able to classify the 15 published braces into nine groups.
“This is the first edition of a brace classification that we expect to evolve further in future due to better understanding and more research – explains prof. Stefano Negrini, Scientific Director of Isico and first author of the article – It is based on expertise more than evidence, but we also must recognize that expertise is the first step of the pyramid of evidence when no better research data are available. Moreover, this expertise is shared worldwide among some of the best brace experts. The involvement and support of the leading scientific societies in the field should guarantee its dissemination”.
Watch the short video commentary of Prof. Stefano Negrini about the published study for our Isico Science corner video column

eSosort2021: Isico competes for the AWARD

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Isico, too will be present with several presentations at the annual international conference Sosort, online from April 29th to May 1st.
A presence, albeit virtual, characterized by the possibility of competing again for the SOSORT Award. We recall that Isico has been awarded already in the last two years the prestigious international recognition given by SOSORT for the best research, to which is added, in 2019, the Award won as co-authors of a research study in collaboration with the University of Hong Kong.

“In this online edition, our study Efficacy of bracing in infantile scoliosis. A 4-years prospective cohort shows that idiopathic respond better than secondary scoliosis will compete for the Award along with six other studies – explains Prof Stefano Negrini, scientific director of Isico and first author of the research – an important result that recognizes the high quality of the research we are performing in Isico. Also, the study Adults with idiopathic scoliosis: progression over 5 Cobb degrees is predicted by menopause and metabolic bone disease, which sees as first author Dr Sabrina Donzelli (who won the Award in 2020) was nominated among the 7 best research studies: Dr. Donzelli will hold the presentation but will not compete for the Award this year.”
In addition, another study, Increasing Brace Comfort, Durability and Sagittal Balance through Semi-rigid Pelvis Material does not change Short-Term Very-Rigid Sforzesco Brace Results, is among those selected for the Podium presentation and will be presented during the event by Dr Francesco Negrini, an Isico physiatrist.

Isico also distinguished itself for the works accepted as Posters, available to subscribers to the event in an on-demand session, and they are three: Can the tilt-differences of limiting vertebrae be a prognostic factor for the worsening of the scoliosis curves treated with specific exercises? A pilot study using a series of matched patients, edited by our director of physiotherapy, Michele Romano, Reducing the pelvis constriction changes the sagittal plane in the brace. A retrospective case-control study of 37 free-pelvis vs 336 classical consecutive very-rigid Sforzesco braces and The modular MI-brace is as effective as the classical custom-made Sforzesco brace. A matched case-control study of 120 consecutive high-degree female AIS, both from Prof Stefano Negrini.

This year’s virtual meeting will begin with synchronous (live) presentations on Thursday, April 29th and Friday, April 30th, from 9 am to 11 am Eastern Time, and on Saturday, May 1st, from 9 am to 1 pm Eastern Time.

All the presentations will be recorded and be made available on-demand for a duration of 1 year on the SOSORT conference website for registered participants. For more information and registration, visit the event website https://esosort21.sosort.org

Scoliosis: is aesthetics measurable?

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When it comes to scoliosis therapy, aesthetics is one of the goals along with a healthy back.

Aesthetic deformity due to scoliosis and its impact on the patient is considered by the members of SOSORT (International Society On Scoliosis Orthopaedic and Rehabilitation Treatment) as the most important reason for treating AIS; unfortunately, only a few of scoliosis studies were found in PubMed on this topic. 

But can a goal, apparently so subjective, be measurable in a repeatable way to become objective? Yes,according to the data collected by the study Reliability, repeatability and comparison to normal of a set of new stereophotogrammetric parameters to detect trunk asymmetries, recently published by the Journal of BIOLOGICAL REGULATORS & Homeostatic Agents. 

“Aesthetic impairment is a crucial issue in Adolescent Idiopathic Scoliosis (AIS), but to date no objective measurements are available – states Dr Francesco Negrini, Isico physiatrist – for our research, we used the Formetric®, which we usually use to measure sagittal planes. We have established parameters for evaluating symmetries in patients, such as those of the shoulder blades or hips, to obtain objective data related to the aesthetic aspect. In order to validate this instrument for clinical practice, the first step and aim of this study are to evaluate the repeatability of the parameters measured by surface topography in a group of AIS subjects and to test if they can distinguish healthy subjects from AIS patients to develop an objective tool for deformity evaluation of the trunk in AIS patients. For our evaluations, we used a device for surface topography based on the principles of rasterstereography. This device (Formetric®, Diers Biomedical Solutions) can reconstruct digitally in three dimensions the back of any person”.

The study evaluated 15 selected parameters that could be good predictors of scoliosis’ impact on the patients’ trunk.
“We analysed short-term (30 seconds, 38 subjects) and medium-term (90 minutes, 14 subjects) repeatability of surface topography measures and their diagnostic validity in AIS (74 subjects, 33 AIS patients and 41 healthy subjects) – proceeds Dr Negrini – All examined parameters were highly correlated as far as short, and medium-term repeatability is concerned”. 

When it comes to aesthetics we cannot stop at Cobb degrees alone, believing that there is no objective measure: “Symmetries can be measured repetitively, as we did in our study – concludes Dr Negrini – so we can offer an objective measurement of aesthetics in patients with idiopathic scoliosis. The surface topography showed good repeatability. Moreover, some of its parameters are correlated with scoliosis, showing that it could very well evaluate deformity due to this pathology. Thanks to these findings, it will be possible to develop a tool that can objectively evaluate aesthetics in AIS patients.”.